Pelvic Pain: The Role of Scar Tissue

Scar tissue is a common contributing factor to pelvic pain. The good news is: it’s an issue that’s highly treatable with PT.

In this blog, I plan to give you the rundown of how scar tissue can impair the pelvic floor as well as how PT and self-treatment can successfully treat these impairments.

Before we get into what scar tissue does, let’s take a look at what it is. Scar tissue is fibrous tissue that replaces normal tissue after an injury. It’s made of the same stuff as the tissue it replaces—collagen. However, the quality of the collagen is inferior to the tissue it replaces. Plus, the tissue is usually not as elastic as the original tissue. This is especially the case with a keloid scar, one type of scar that is extremely restricted and raised.

It’s important to bear in mind that the scar that you can see is actually only the tip of the iceberg as most scars extend deeper into the body than the bit of scar that is outwardly visible.

Scarring that affects the pelvic floor can happen as a result of any trauma to the area, including a C-section, perineum tear or episiotomy during childbirth as well as a prostatectomy, a hysterectomy, a vasectomy, bowel surgery, endometriosis surgery, bartholin’s abscess removal, or physical injury.

And there are three major ways that scarring within or adjacent to the pelvic floor can cause problems:

First, scar tissue is indiscriminate in what it attaches to. So it can adhere to skin, muscle, or connective tissue. Wherever it decides to hang out, it pulls on the surrounding tissue making the area taut and restricting blood flow, a situation that often results in pain.

For instance, we have a patient who had a bartholin’s abscess removed. The abscess was buried within her pelvic floor. The scar tissue that resulted from the surgery now causes pain to the internal pelvic floor muscles that surround it.

The patient presents with pain in the area surrounding her scar because the tissue isn’t getting the blood flow and oxygen that it needs.

Another way that scar tissue can wreak havoc within the pelvic floor is as a result of referred pain. Remember, there is a network of nerves that innervate the pelvic floor. If a scar is on top of or impinging on a nerve that also innervates another part of the pelvic floor, then that area can also be affected.

For example, C-section scars are typically located in an area where they can entrap a nerve that also innervates the urethra. This, in turn, causes pain to the urethra. Nerves like to be able to slide and glide, but if the tissue around them is tight, they don’t have the mobility they need. Therefore, a woman with a C-section scar that bears down on the nerve that also feeds into the urethra can experience urethral burning, urgency, or frequency.

In addition to urethral problems, a C-section scar can cause clitoral pain for the same reason—because the scar entraps the nerve that also innervates the clitoris.

What’s more, the round ligament that attaches from the sides of the uterus to the labia can be caught in scar tissue after a C-section because the incision is also right over the area where the round ligament crosses the pelvic brim. If this happens, a woman can experience labial pain, especially with transitional movements like going from a seated position to a standing position.

That’s why it’s important to remember that the pain and dysfunction caused by a scar is not always going to be in the area where the scar is located.

Another way scar tissue can cause problems within the pelvic floor is by impairing function in the area where it’s located. The pelvic floor is a major hub of the body. Muscles, nerves, connective tissue, and organs are all located there, and they all have important jobs to do, such as keeping us continent.

For instance, if a muscle is torn and then a scar forms—as in an anal sphincter tear during a difficult childbirth——that muscle may lose some of its ability to contract, which could lead to a loss of control over urination, bowel movements, or sexual function.

So how scar tissue treated in PT?

In all cases, a scar can be made more flexible by manipulating the scar tissue. The more scar tissue is moved and massaged, the softer and more similar to the tissue around it it becomes. This reduces tightness and breaks up adhesions (an “adhesion” occurs when scar tissue attaches to a nearby structure).

So if a scar is pulled in all directions, the body will lay down the fibers of the scar tissue with more organization, and in a similar alignment to the tissues around it. This results in the scar blending in better and behaving more like normal tissue.

What this means during your PT treatment is that the therapist will massage and manipulate your scar tissue and the area around it. Scars (internal and external) can be pushed, pulled, pinched, rolled, and rubbed.

Warning: manipulating a scar can be painful. That’s because tissue that has restricted blood flow is super-sensitive to touch, so treatment can be painful, and sometimes breaking up an adhesion can cause temporary discomfort.

But, this is a pain that comes with gain. Ultimately, scar mobilization promotes collagen remodeling, which increases pliability of the tissues and reduces uncomfortable sensations, such as itching or sensitivity.

It’s best to start scar mobilization early in the healing process, usually six to eight weeks after the trauma that caused the scar. The reason that early intervention is ideal is because the tissue will respond quickest during this period.

However, the body remodels scar tissue constantly, so your tissues are being replaced with new tissue all the time, just at a much slower rate when scar tissue is older. So scar mobilization can help with scar tissue and adhesions that are years old. Scar mobilization can be performed on scars anywhere on the body including the abdomen, pelvis, and vagina and can also be used to desensitize the area surrounding the scar, which often becomes extremely sensitive to touch.

Physical therapists can perform scar mobilization and also instruct patients on how to perform the mobilization at home if appropriate.

Scar tissue mobilization has a definite payoff. For instance, one of my patients had bowel surgery that included an incision on his left lower abdomen eight months ago. As a result, his pain levels were an 8/10 in his left testicle, and he had pain with urination and ejaculation. Upon examination, he had a restricted scar and tight abdominal and pelvic floor muscles. I taught him how to massage his scar and relax his pelvic floor, and after eight visits, his pain is down to a 2/10, and I foresee additional improvement for him.

I hope I have done a good job explaining how scar tissue can impact the pelvic floor and how it can be treated with PT and self-treatment.

But if you have any questions on this topic, please do not hesitate to leave them in the comments section below!